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Induction of labour
This booklet will help you to make informed choices about induction of labour (IOL). This leaflet is not meant to replace the discussion between you and your healthcare team, but can help you understand more about what is discussed.
If you have any further questions please do not hesitate to speak to your healthcare team.
What is induction of labour (IOL) and why is it being offered?
IOL is a process designed to start labour artificially. In the UK around one in every 3–4 labours are started using induction.
We use different methods which try to replicate the process that occurs naturally during spontaneous labour – explained below – to help soften and efface (thin out) the cervix (neck of the womb), also known as ripening.
There are a number of clinical reasons for IOL the most common being:
- your pregnancy going past 41 weeks (prolonged pregnancy)
- your waters (membranes) have released before labour starts
- if there is concern about the health and wellbeing of you or your baby.
There are many different reasons why IOL can be offered and this will be discussed with you by either your doctor (obstetrician) or midwife. An individualised care plan will be agreed with you.
Can I help myself go into labour naturally before my IOL date?
You may be offered a membrane sweep, which is a vaginal (internal) examination, performed by either your midwife or doctor prior to your IOL date. They will gently examine and stretch your cervix which stimulates your body’s natural labour hormones. It may cause some mild discomfort, or very light bleeding, but it can increase the chance of your body going into labour naturally. You may wish to keep mobile and active as this can help prepare your body for labour. Sitting rather than lying down, or the use of a birthing ball and gentle walking are all examples.
How will I be induced?
Depending on the reason, your IOL will either take place on Lexden Ward or the Delivery Suite and you will be informed of this when your IOL is booked. Please call two hours before to check that we have a bed available.
Upon arrival, you will be welcomed to the ward by a midwife and a full antenatal assessment and discussion regarding IOL will take place. This is another opportunity for you to ask any questions you may have about the IOL process.
Your midwife will then monitor your baby’s heart rate for at least 30 minutes using a cardiotocograph (CTG) to ensure the wellbeing of you and your baby.
With your consent, they will then perform a vaginal examination (VE) to assess the readiness of the cervix and decide the most appropriate way to commence your IOL.
Usually the first stage of the IOL process is to use prostaglandins. Prostaglandin is a hormone made by
the body to soften and efface the cervix, also known as ‘ripening’. The prostaglandin used in IOL is made to be similar to that naturally formed in your body. During IOL this prostaglandin is placed within your vagina, alongside your cervix in order to cause ripening.
Although not designed to cause dilation of the cervix or contractions (surges) of your womb (uterus) they can sometimes produce these effects.
Prostaglandins are usually in the form of a Propess® pessary or Prostin® gel.
Propess® pessary (10mg dinoprostone) is a synthetic prostaglandin designed to ripen the cervix. It is left in place for 24 hours and will slowly release dinoprostone to ripen your cervix. The Propess® will be removed earlier if labour starts or there are any concerns about you or your baby.
The Propess® is placed high in the vagina next to the cervix. The pessary looks like a small thin tampon and has a tape attached. Once inserted, the midwife will again monitor your baby’s heart rate for at least 30 minutes using a CTG. During the CTG you will usually sit on the bed, and this gives the
Propess® time to absorb moisture from your vagina making it gently swell and prevent it from falling out when you mobilise.
Your midwife will regularly assess your baby’s heart rate, contractions/surges and pain you may experience and will support you throughout the IOL process, but please let them know if you experience:
- concerns over baby’s movements (change or reduction in movements)
- you feel unwell
- your waters release
- the Propess® falls out
A repeat CTG will be performed six hours following the insertion of the pessary. Depending on the reason for your IOL, you may be able to go home and relax whilst the pessary begins to work. Your doctor or midwife will discuss and plan this with you.
After 24 hours, you will have another vaginal examination to assess your cervix. If the cervix has not ripened adequately for us to release your waters and you are not in labour, further prostaglandins can be used. This is called Prostin®.
Prostin® (1 or 2mg dinoprostone) gel is designed to ripen your cervix and prepare it for labour. It is given during a vaginal examination alongside your cervix and left for six hours to take effect. Your midwife will again monitor your baby’s heart rate, contractions/surges and discomfort in the same way they did following Propess®.
After six hours you will be reassessed and if the cervix has not ripened enough for us to release your waters and/or you are not in labour, further prostaglandins may be used. You may need more than one gel, but this will be reviewed by your doctor and midwife.
If you are having an IOL because your waters released before labour started you will not be offered Propess®, but instead will be offered one dose of Prostin® gel.
Artificial rupture of membranes (ARM)
Artificial rupture of membranes is the medical term used to describe the release of your waters by either your midwife or doctor. Once cervical ripening has occurred, the next step in the IOL process is to release your waters. It is necessary for the waters to be released before starting the oxytocin drip so this is an important element of the IOL process. A vaginal examination is performed and a small hole is made in the membrane sac surrounding your baby using a slim, sterile instrument. You may experience some discomfort, but it will not harm you or your baby.
This will take place on the Delivery Suite but please be aware that sometimes there may be delays transferring you due to how busy the unit is. Throughout this process you and your baby’s safety is important and only when it is safe to commence or continue, will the IOL occur. We will keep you informed at all times.
Once your midwife or doctor has released your waters, they will either suggest waiting for 2–4 hours before the next stage of IOL or starting the next stage immediately. This decision will often depend on your individual circumstances, for example, whether you are already experiencing strong contractions/surges, or if your cervix is already dilated. This will be discussed with you at the time and you will be kept fully informed.
The next stage of the IOL will be using an intravenous infusion of oxytocin.
Oxytocin is a hormone produced naturally in your body which is essential to the onset and maintenance of contractions in labour. During IOL if you have not already started having strong contractions/surges, we use synthetic oxytocin to start and maintain your contractions. This will be given to you through a small tube placed in a vein in either your hand or arm. You are given a small dose at first and then the midwife will increase it slowly until you are having regular and strong contractions until the birth of your baby.
Once the oxytocin drip has started, your baby’s heart will need to be continuously monitored with a CTG.
Getting into the active phase of labour in hospital or at home
You can help your body to produce its own birth hormones by relaxing and working with your body.
- Read the tips for labour and birthing partners in the folder found on the ward
- Keep fed and hydrated – your body will tell you what you need
- Make sure to keep mobile – babies like the feeling of movement as you walk around and change position
How long does an induction take?
This will be different for every woman and depends on how ready your cervix is for birth. Generally, it can take 2–5 days from the start of your induction to the birth of your baby. Bring plenty to entertain yourselves!
Sometimes the maternity department and hospital are very busy, and this may delay some or all of your induction but your midwife will keep you fully informed.
Are there any risks or disadvantages of IOL?
Induction of labour is a medical intervention that may affect your birth options and your experience of the birth process.
- The artificial hormones used with IOL may cause hyperstimulation – this is when your womb contracts too frequently or contractions last too long which can lead to changes to your baby’s heart rate pattern. The midwife will monitor this closely and if this occurs may remove the Propess® or stop the oxytocin drip. We also have medication which can help to reduce contractions.
- Your choice of place of birth will be limited as you may require interventions, for example, oxytocin infusion (drip), continuous fetal heart rate monitoring or an epidural.
- It is recommended that your baby is continuously monitored with the CTG when the oxytocin drip is used for IOL. Please speak to your midwife about different ways to mobilise.
- Induced labour can be more painful than spontaneous labour as you do not have a natural build-up of contractions; therefore, women who are induced are more likely to ask for an epidural.
- There may be a need for an assisted vaginal birth (using forceps or ventouse), with the associated increased risk of obstetric anal sphincter injury (for example, third- or fourth-degree perineal tears).
- You may require more vaginal examinations during IOL.
- There may be limitations on the use of a birthing pool.
- Your hospital stay may be longer than with a spontaneous labour.
- IOL is not always successful.
What pain relief can I have?
If you are having IOL you may want to think about your birth plan with regard to pain relief. Adequate pain relief is important during IOL and different options are available.
It is important for you to understand and ask about these options. Both your midwife in the community and the midwives in the hospital can give you advice. There are also leaflets available specifically about pain relief in labour and on the Mum and Baby app.
There are additional techniques to replace or complement the use of medication. You may want to consider, and we would recommend, being mobile, birthing balls and a bath/shower which we have available for you on the wards.
The use of breathing techniques and hypnobirthing can also help. You may wish to hire or purchase a TENS machine to help you. TENS machines work by blocking or reducing the pain signals going to your spinal cord and brain and this will help reduce your pain – they are ideal in the early phase of
What happens if my IOL does not work?
If you do not go into labour following the IOL process, your midwife and doctor will discuss your options with you.
Depending on your circumstances and wishes you may be offered:
- the option to stop the IOL and rest for a day or more and attempt the process again
- a Caesarean section birth
Can I have someone with me?
Dependent on COVID-19 restrictions, you may have your birthing partner with you on Lexden Ward until 8pm. If, however, the midwife feels you need extra support or it’s very likely you are going into labour after this time, your birthing partner may stay with you. If not, our staff will politely ask your partner to go home to rest and they will be called back in if labour is established during the night.
Once on the Delivery Suite you may have two birthing partners with you at all times if you wish.
We ask that birthing partners bring in their own refreshments and facemasks and reduce their movement around the ward.
What if I decide not to have an IOL?
If you decide IOL is not an option you would like to choose, then you will have the opportunity to discuss this with your midwife and doctor. This discussion should be an opportunity for us to explore with you your concerns and give you the information you need to support your decision.
This discussion will explore the rationale for the offer of IOL, especially why we are suggesting it, as well as if there is a chance of any complications for either you or your baby should you choose to decline or delay IOL. This will of course be based on your individual care and the most up-to-date information we have from national guidance. Ultimately, it is your choice whether to go ahead or not.
If you decide to decline or delay the offer of IOL, you will be offered increased antenatal surveillance which includes monitoring of you and your baby. However, this monitoring cannot predict you or your baby’s wellbeing and complications can still occur. A personalised plan will be suggested by your healthcare professionals.
Useful sources of information
National Institute for Health and Care Excellence (2021)
National Institute for Health and Care Excellence (2021) Inducing Labour NICE Guideline
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